Effect of daily stressors and collective efficacy on post-traumatic stress symptoms among internally displaced persons in post-war northern Sri Lanka

BACKGROUND

Daily stressors have been shown to mediate the relationship of war trauma and trauma-related distress among refugees and internally displaced persons exposed to war and conflict.

AIMS

To examine the extent to which the relationship between war-related trauma and mental distress was mediated by daily stressors and collective efficacy among internally displaced communities a decade after exposure to war.

METHOD

In a cross-sectional study, we recruited a random sample of residents in villages severely affected by conflict in five districts in the Northern Province of Sri Lanka. Measures of war trauma, daily stressors, collective efficacy and post-traumatic stress symptoms (PTSS) were examined. Statistical analyses of the mediating and moderating effects of daily stressors were conducted using regression based methods.

RESULTS

Daily stressors mediated the association of war trauma and PTSS, as both paths of the indirect effect, war trauma to daily stressors and daily stressors to PTSS, were significant. The predictive effect of war trauma on PTSS was positive and significant at moderate and high levels of daily stressors but not at low levels. Higher levels of neighbourhood informal social control, a component of collective efficacy, function as a protective factor to reduce effects of war trauma and daily stressors on mental distress in this population.

CONCLUSIONS

Daily stressors are an important mediator in the well-established relationship between war exposure and traumatic stress among internally displaced persons, even a decade after the conflict. Mental health and psychosocial support programmes that aim to address mental distress among war-affected communities could reduce daily stressors and enhance collective efficacy in this context.

Treatment of massive trauma due to war

Treatment of trauma has been already covered in this journal (Adshead, 1995) and elsewhere (Davidson, 1992; Kleber & Brom, 1992; Wilson & Raphael, 1993). However, there are situations where the trauma can become extensive and chronic, sometimes called Type II trauma (Terr, 1991), necessitating additional therapeutic considerations. Such situations are not uncommon in the world today, frequently occurring during wars that are typically ‘low-intensity’ conflicts involving poor, Third World countries. It has been estimated that there have been over 150 such wars since 1945, in which 90% of all casualties are civilians. According to Summerfield (1996), what predominates is the use of terror to exert social control, if necessary by disrupting the social, economic and cultural structures. The target is often population rather than territory and psychological warfare is the central element. Atrocities, including civilian massacres, reprisals, bombing, shelling, mass displacements, disappearances and torture are the norm. The consequences for mental health, not to mention the social, economic, cultural and other costs, can be substantial.

A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD

The World Health Organization's proposals for posttraumatic stress disorder (PTSD) in the 11th edition of the International Classification of Diseases, scheduled for release in 2018, involve a very brief set of symptoms and a distinction between two sibling disorders, PTSD and Complex PTSD. This review of studies conducted to test the validity and implications of the diagnostic proposals generally supports the proposed 3-factor structure of PTSD symptoms, the 6-factor structure of Complex PTSD symptoms, and the distinction between PTSD and Complex PTSD. Estimates derived from DSM-based items suggest the likely prevalence of ICD-11 PTSD in adults is lower than ICD-10 PTSD and lower than DSM-IV or DSM-5 PTSD, but this may change with the development of items that directly measure the ICD-11 re-experiencing requirement. Preliminary evidence suggests the prevalence of ICD-11 PTSD in community samples of children and adolescents is similar to DSM-IV and DSM-5. ICD-11 PTSD detects some individuals with significant impairment who would not receive a diagnosis under DSM-IV or DSM-5. ICD-11 CPTSD identifies a distinct group who have more often experienced multiple and sustained traumas and have greater functional impairment than those with PTSD.

PIXEL SENSIBLE LOCAL BAND ANALYSIS IN MICROSCOPIC CHROMOSOME IMAGES USING CSPA

In chromosome analysis, local band analysis plays the main role to identify the perfect matched chromosome in metaspread images to attain the karyotyping. Literature investigations are narrow in chromosome image band analysis due to the higher complexities. In this paper, Pixel level based Conditional Seed Point Algorithm (CSPA) is proposed. This simulation algorithm separates the weak band region to the strong band region, and the strong band region area evaluated was based on the Region of Seed condition Points. This algorithm works well for different intensity levels and adopts the structural changes to identify the bands in image. This algorithm was simulated in more than 450 individual chromosomes to identify the local bands in the chromosome images and provided the accuracy more than 96%.

Vicarious resilience and vicarious traumatisation: Experiences of working with refugees and asylum seekers in South Australia

The negative psychological impacts of working with traumatised people are well documented and include vicarious traumatisation (VT): the cumulative effect of identifying with clients' trauma stories that negatively impacts on service providers' memory, emotions, thoughts, and worldviews. More recently, the concept of vicarious resilience (VR) has been also identified: the strength, growth, and empowerment experienced by trauma workers as a consequence of their work. VR includes service providers' awareness and appreciation of their clients' capacity to grow, maintaining hope for change, as well as learning from and reassessing personal problems in the light of clients' stories of perseverance, strength, and growth. This study aimed at exploring the experiences of mental health, physical healthcare, and settlement workers caring for refugees and asylum seekers in South Australia. Using a qualitative method (data-based thematic analysis) to collect and analyse 26 semi-structured face-to-face interviews, we identified four prominent and recurring themes emanating from the data: VT, VR, work satisfaction, and cultural flexibility. These findings-among the first to describe both VT and VR in Australians working with refugee people-have important implications for policy, service quality, service providers' wellbeing, and refugee clients' lives.

Recent disasters in Sri Lanka: lessons learned

Sri Lanka has faced several disasters in the recent past, both manmade and natural. The mental health and psychosocial consequences have been felt at the individual, family, and collective levels. Individuals developed normal distress, posttraumatic stress disorder, depression, or alcohol abuse. There were changes in family and social processes causing a tearing of the social fabric, lack of social cohesion, disconnection, mistrust, hopelessness, dependency, lack of motivation, powerlessness, and despondency. Because of the widespread nature of mental health needs, a community approach would reach the most number of people.

Rebuilding community resilience in a post-war context: developing insight and recommendations - a qualitative study in Northern Sri Lanka

BACKGROUND

Individuals, families and communities in Northern Sri Lanka have undergone three decades of war trauma, multiple displacements, and loss of family, kin, friends, homes, employment and other valued resources. The objective of the study was understanding common psychosocial problems faced by families and communities, and the associated risk and protective factors, so that practical and effective community based interventions can be recommended to rebuild strengths, adaptation, coping strategies and resilience.

METHODS

This qualitative, ecological study is a psychosocial ethnography in post-war Northern Sri Lanka obtained through participant observation; case studies; key- informant interviews; and focus groups discussions with mental health and psychosocial community workers as well as literature survey of media and organizational reports. Qualitative analysis of the data used ethnography, case studies, phenomenology, grounded theory, hermeneutics and symbolic interactionism techniques. Quantitative data on suicide was collected for Jaffna and Killinochchi districts.

RESULTS

Complex mental health and psychosocial problems at the individual, family and community levels in a post-war context were found to impair recovery. These included unresolved grief; individual and collective trauma; insecurity, self-harm and suicides; poverty and unemployment; teenage and unwanted pregnancies; alcoholism; child abuse and neglect; gender based violence and vulnerability including domestic violence, widows and female headed-household, family conflict and separation; physical injuries and handicap; problems specific for children and elderly; abuse and/or neglect of elderly and disabled; anti-social and socially irresponsible behaviour; distrust, hopelessness, and powerlessness. Protective factors included families; female leadership and engagement; cultural and traditional beliefs, practices and rituals; and creative potential in narratives, drama and other arts. Risk factors that were impeding community rehabilitation and recovery included continuing military governance, depletion of social capital particularly lack of trust, hope and socio-economic opportunity structures for development that would engender a sense of collective efficacy.

CONCLUSIONS

In view of the widespread trauma at the individual, family and collective levels, community based programmes to increase local awareness, knowledge and skills to deal with common mental health and psychosocial issues; and training of community level workers and others in basic mental health and psychosocial problem solving are recommended to rebuild family and community agency and resilience. The use of cultural practices and school based programmes would rekindle community processes.

Collective trauma in the Vanni- a qualitative inquiry into the mental health of the internally displaced due to the civil war in Sri Lanka

BACKGROUND

From January to May, 2009, a population of 300,000 in the Vanni, northern Sri Lanka underwent multiple displacements, deaths, injuries, deprivation of water, food, medical care and other basic needs caught between the shelling and bombings of the state forces and the LTTE which forcefully recruited men, women and children to fight on the frontlines and held the rest hostage. This study explores the long term psychosocial and mental health consequences of exposure to massive, existential trauma.

METHODS

This paper is a qualitative inquiry into the psychosocial situation of the Vanni displaced and their ethnography using narratives and observations obtained through participant observation; in depth interviews; key informant, family and extended family interviews; and focus groups using a prescribed, semi structured open ended questionnaire.

RESULTS

The narratives, drawings, letters and poems as well as data from observations, key informant interviews, extended family and focus group discussions show considerable impact at the family and community. The family and community relationships, networks, processes and structures are destroyed. There develops collective symptoms of despair, passivity, silence, loss of values and ethical mores, amotivation, dependency on external assistance, but also resilience and post-traumatic growth.

CONCLUSIONS

Considering the severity of family and community level adverse effects and implication for resettlement, rehabilitation, and development programmes; interventions for healing of memories, psychosocial regeneration of the family and community structures and processes are essential.

Possession states in Northern Sri Lanka

BACKGROUND

Possession states are still commonly seen in developing societies as acceptable cultural phenomena in normal persons as well as in those with psychiatric illness. 'Possession' is defined here as the experience of being taken over, controlled or occupied by another spirit or force.

SAMPLING AND METHODS

This is a descriptive cross-sectional study of possession states among psychiatric patients, general population and popular adepts in Northern Sri Lanka, using semi-structured questionnaires and clinical observations.

RESULTS

Thirty psychiatric patients were identified as having possession states. They were compared with 30 controls each from the general population admitted to a general hospital outpatient department and selected popular adepts in the community. The latter are individuals who are well known as having possession states. An analysis of social factors and other variables showed that education, marital status, age, employment, strength of belief, alterations in personality, past or family psychiatric history, previous exposure to similar phenomena, help-seeking behavior and treatment outcome differed between the three groups. Religion of the subjects or recent changes in values showed no correlation with possession while monetary gain from possession states showed only a partial correlation. Western medical treatment was of value only when possession states were seen as part of psychotic illness.

DISCUSSION

Possession is a spectrum of experiential and behavioral phenomena seen in culturally acceptable form in normal people, popular adepts, as well as manifestations of psychotic illness. Possession states which fit normal cultural stereotypes could, if necessary, be better managed by traditional methods. However, clinicians need to be familiar with culturally abnormal forms of possession which are manifestations of psychotic illness that benefit from western psychiatric treatment.

Collective trauma in northern Sri Lanka: a qualitative psychosocial-ecological study

BACKGROUND

Complex situations that follow war and natural disasters have a psychosocial impact on not only the individual but also on the family, community and society. Just as the mental health effects on the individual psyche can result in non pathological distress as well as a variety of psychiatric disorders; massive and widespread trauma and loss can impact on family and social processes causing changes at the family, community and societal levels.

METHOD

This qualitative, ecological study is a naturalistic, psychosocial ethnography in Northern Sri Lanka, while actively involved in psychosocial and community mental health programmes among the Tamil community. Participatory observation, key informant interviews and focus group discussion with community level relief and rehabilitation workers and government and non-governmental officials were used to gather data. The effects on the community of the chronic, man-made disaster, war, in Northern Sri Lanka were compared with the contexts found before the war and after the tsunami.

RESULTS

Fundamental changes in the functioning of the family and the community were observed. While the changes after the tsunami were not so prominent, the chronic war situation caused more fundamental social transformations. At the family level, the dynamics of single parent families, lack of trust among members, and changes in significant relationships, and child rearing practices were seen. Communities tended to be more dependent, passive, silent, without leadership, mistrustful, and suspicious. Additional adverse effects included the breakdown in traditional structures, institutions and familiar ways of life, and deterioration in social norms and ethics. A variety of community level interventions were tried.

CONCLUSION

Exposure to conflict, war and disaster situations impact on fundamental family and community dynamics resulting in changes at a collective level. Relief, rehabilitation and development programmes to be effective will need to address the problem of collective trauma, particularly using integrated multi-level approaches.

The psychosocial effects of landmines in Jaffna

The victims of landmines in Jaffna were studied from a psychosocial perspective in order to identity major problem areas and give priorities for rehabilitation. Sixty-seven victims of landmines from April 1996 to March 1998 in the Valikamam area of Jaffna were studied. There were three times as many males as females. About 48 per cent were aged 20-39 years. About one-fifth of the victims were children. Of the females, 60 per cent were unmarried. The majority belonged to the lower socioeconomic strata. Half lost their earning capacity after the injury. Post-traumatic stress disorder (72 per cent), acute stress reaction (73 per cent), anxiety disorder (80 per cent) and depression (73 per cent) were found to be very significantly higher in this group than in the general population. There were also remarkable changes in the areas of functional ability, religious practice, use of alcohol and social relationships. The 'phantom limb' phenomenon was a striking feature among amputees. The psychosocial impact of landmine injuries has to be considered seriously in rehabilitation work.

Lifetime events and posttraumatic stress disorder in 4 postconflict settings

CONTEXT

Little is known about the impact of trauma in postconflict, low-income countries where people have survived multiple traumatic experiences.

OBJECTIVE

To establish the prevalence rates of and risk factors for posttraumatic stress disorder (PTSD) in 4 postconflict, low-income countries.

DESIGN, SETTING, AND PARTICIPANTS

Epidemiological survey conducted between 1997 and 1999 among survivors of war or mass violence (aged >/=16 years) who were randomly selected from community populations in Algeria (n = 653), Cambodia (n = 610), Ethiopia (n = 1200), and Gaza (n = 585).

MAIN OUTCOME MEASURE

Prevalence rates of PTSD, assessed using the PTSD module of the Composite International Diagnostic Interview version 2.1 and evaluated in relation to traumatic events, assessed using an adapted version of the Life Events and Social History Questionnaire.

RESULTS

The prevalence rate of assessed PTSD was 37.4% in Algeria, 28.4% in Cambodia, 15.8% in Ethiopia, and 17.8% in Gaza. Conflict-related trauma after age 12 years was the only risk factor for PTSD that was present in all 4 samples. Torture was a risk factor in all samples except Cambodia. Psychiatric history and current illness were risk factors in Cambodia (adjusted odds ratio [OR], 3.6; 95% confidence interval [CI], 2.3-5.4 and adjusted OR,1.6; 95% CI, 1.0-2.7, respectively) and Ethiopia (adjusted OR, 3.9; 95% CI, 2.0-7.4 and adjusted OR, 1.8; 95% CI, 1.1-2.7, respectively). Poor quality of camp was associated with PTSD in Algeria (adjusted OR, 1.8; 95% CI, 1.3-2.5) and in Gaza (adjusted OR, 1.7; 95% CI, 1.1-2.8). Daily hassles were associated with PTSD in Algeria (adjusted OR, 1.6; 95% CI, 1.1-2.4). Youth domestic stress, death or separation in the family, and alcohol abuse in parents were associated with PTSD in Cambodia (adjusted OR, 1.7; 95% CI, 1.1-2.6; adjusted OR, 1.7; 95% CI, 1.0-2.8; and adjusted OR, 2.2; 95% CI, 1.1-4.4, respectively).

CONCLUSIONS

Using the same assessment methods, a wide range of rates of symptoms of PTSD were found among 4 low-income populations who have experienced war, conflict, or mass violence. We identified specific patterns of risk factors per country. Our findings indicate the importance of contextual differences in the study of traumatic stress and human rights violations.